Hypertension Guideline

Transcription

1 DEPARTMENT OF HEALTH Hypertension Guideline Third Edition Professional Development & Quality Assurance Clinical Audit and Guideline Group Nov 2008

2 CONTENT 1. INTRODUCTION DEFINITION AND CLASSIFICATION OF HYPERTENSION INITIAL ASSESSMENT AIMS PHYSICAL EXAMINATION INVESTIGATIONS INITIAL ASSESSMENT FORM MANAGEMENT OF HYPERTENSION GOAL OF THERAPY FLOW CHART OF MANAGEMENT OF HYPERTENSION MANAGEMENT PROTOCOL OF LIFESTYLE MEASURES DRUG TREATMENT FOR HYPERTENSION REFERRAL ACCIDENT & EMERGENCY DEPARTMENT REFERRAL HOSPITAL CLINIC REFERRAL...9 APPENDIX I EQUIPMENT FOR RECORDING BLOOD PRESSURE...10 APPENDIX II FOLLOW UP...13 APPENDIX III AMBULATORY BP MONITORING FOR WHITE COAT HYPERTENSION...15 APPENDIX IV HOME/ SELF BP MONITORING...17 APPENDIX V LEVELS OF EVIDENCE...18 APPENDIX VI CLASSIFICATION OF OBESITY (WHO IOTF 2000) APPENDIX VII CLINIC AVAILABLE ANTI-HYPERTENSIVE DRUG LIST & COST...20 REFERENCES...21 MEMBERS OF THE CLINICAL AUDIT AND GUIDELINE GROUP, PDQA, DEPARTMENT OF HEALTH...23 DISCLAIMER GUIDELINE AVAILABILITY...24

3 1. Introduction Hypertension is common and is an important cause of strokes, coronary heart disease and premature death 1. In the Hong Kong Cardiovascular Risk Factor Prevalence Study 2, about 1 in 10 men and 1 in 9 women had definite hypertension (defined as systolic BP 160 and/or diastolic BP 95 mmhg or on treatment for hypertension); about 1 in 12 men and 1 in 16 women had borderline hypertension (defined as systolic BP and/or diastolic BP mmhg). 6% of men and 8% of women were on treatment for hypertension overall. Among individuals with definite hypertension, 66% of men and 71% of women were on treatment. Conversely 34% of men and 29% of these women were untreated. After the implementation of the second edition of the hypertension guideline in , newer guidelines were published. There was a major change in drug use supported by new evidence. Thus, the Clinical Audit and Guideline Working Group in Professional Development and Quality Assurance (PDQA) decided to update the part on drug treatment for hypertension. 2. Definition and Classification of Hypertension In the Seventh Report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation and treatment of High Blood Pressure, the classification of blood pressure for adults ages 18 and older is based on the average of two or more properly measured, seated BP readings on each of two or more office visits. JNC classification Category SBPmmHg DBPmmHg Normal <120 and < 80 Prehypertension or Stage 1 hypertension or Stage 2 hypertension 160 or 100 A new category designated prehypertension (systolic BP of mmHg or a diastolic BP of 80-89mmHg) has been added. Adults with prehypertension are at twice the risk to develop hypertension as those with lower values 8. Page 2

4 3. Initial Assessment Aims i. To assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment (Table 1) ii. To reveal identifiable causes of high BP (Table 2) iii. To assess the presence or absence of target organ damage and CVD (Table 3) Table 1 Cardiovascular risk factors Hypertension Cigarette smoking Obesity Physical inactivity Dyslipidemia Diabetes mellitus Microalbuminuria or estimated GFR<60ml/min Age (older than 55 for men, 65 for women) Family history of premature cardiovascular disease (men under age 55 or women under age 65) Table 2 Identifiable causes of hypertension Sleep apnea Drug-induced Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease Table 3 Target Organ Damage Heart - Left ventricular hypertrophy - Angina or prior myocardial infarction - Prior coronary revascularization - Heart failure Brain - Stroke or transient ischemic attack Chronic kidney disease Perpheral arterial disease Retinopathy 3.2 Physical Examination i. Body mass index (BMI). ii. Cardiovascular system: peripheral pulses, carotid bruit, apex beat, heart murmurs, oedema/heart failure. iii. Abdominal system: abdominal and femoral bruits, enlarged kidney, masses and abnormal aortic pulsation. iv. Optic fundi. v. Neurological examination to exclude evidence of cerebral vascular damage. vii. Palpation of thyroid gland. Page 3

5 3.3 Investigations i. Urinalysis for blood, protein and glucose. ii. iii. iv. Blood for serum electrolytes, creatinine, fasting glucose, fasting lipid profile Electrocardiogram (ECG). Other tests if indicated. 3.4 Initial Assessment Form This form should be completed within 6 months for a client with newly diagnosed hypertension. Staff responsibility for the different sections is allocated by the individual clinics at their own discretion. Abnormalities found should be given in more details e.g. degree of retinopathy or abnormality of ECG. Hypertension-Initial assessment Completion date: ID No. : Input: ( ) Health education : = done ( ) Optimal weight ( ) Antismoking ( ) Nature of HT and risk factors ( ) Advice on alcohol ( ) Exercise ( ) Low salt diet Physical examinations : Date : = present X = absent BMI : BP : / N = normal A = abnormal CVS : ( ) Heart failure Abdomen: ( ) Enlarged kidney ( ) LVH ( ) Abdominal bruit ( ) Heart murmur Others: ( ) Carotid bruit Retinopathy ( ) R ( ) L ( ) Cerebrovascular damage Peripheral pulses ( ) R ( ) L Investigations : Date : Na / K ( / ) Cholesterol (total/ldl/hdl) ( / / ) ECG Normal/Abnormal Creatinine ( ) Urine protein ( -/trace/+/++/+++ ) FBS ( ) Other ( ) Risk Factors : = present X = absent ( ) Smoker ( ) Insuff. Exercise ( ) Obesity ( ) FH premature CAD ( ) Excess alcohol ( ) Raised cholesterol ( ) DM Complications : = present X = absent ( ) LVH ( ) Heart failure ( ) PVD ( ) Renal disease ( ) Angina ( ) Retinopathy ( ) Stroke Page 4

6 4. Management of Hypertension 3,4 4.1 Goal of Therapy Simple hypertensive subjects Patients with diabetes mellitus or chronic renal disease <140/90mmHg <130/80mmHg 4.2 Flow Chart of Management of Hypertension LIFESTYLE MODIFICATIONS Not at Goal Blood Pressure (<140/90 mmhg) (<130/80 mmhg for patients with diabetes or chronic kidney disease) INITIAL DRUG CHOICES Without Compelling Indications With Compelling Indications Step 1 <55 years A 55 years or black patients of any age C or D Drug(s) for the compelling indications (See 4.4.2) Step 2 A+C or A+D A+C or A+D Step 3 A+C+D A+C+D NOT AT GOAL BLOOD PRESSURE Step 4 Add further diuretic therapy or alpha-blocker or beta-blocker. Consider consultation with hypertension specialist. Page 5

7 Abbreviations: DBP= diastolic blood pressure SBP= systolic blood pressure. A=angiotensin converting enzyme inhibitor (consider angiotensin-ii receptor antagonist if ACE inhibitor intolerant) B=beta-blocker C=calcium channel blocker D=thiazide-type diuretic Black patients are those of African or Caribbean descent, and not mixed-race, Asian or Chinese patients 4.3 Management Protocol of Lifestyle Measures 3 Adoption of healthy lifestyles by all persons is critical for the prevention of high BP and is an indispensable part of the management of those with hypertension. Lifestyle modifications can reduce BP, enhance antihypertensive drug efficacy, and decrease cardiovascular risk. Lifestyle modifications to manage hypertension * MODIFICATION Weight reduction Adopt DASH eating plan 25 RECOMMENDATION Maintain normal body weight (body mass index kg/m 2 ) Consume diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat. APPROXIMATE SBP REDUCTION (RANGE) 5-20 mmhg/10kg Weight loss 8-14 mmhg Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). 2-8 mmhg Physical activity Moderation of alcohol consumption Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week). Limit consumption to no more than 2 drinks (1 oz or 30 ml ethanol; e.g., 24 oz beer, 10 oz wine, or 3 oz or 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter weight persons. 4-9 mmhg 2-4 mmhg DASH= Dietary Approaches to Stop Hypertension. * For overall cardiovascular risk reduction, stop smoking 11 The effects of these modifications are dose and time dependent and could be greater for some individuals. Page 6

8 4.4 Drug Treatment for Hypertension Principles in the use of anti-hypertensive drugs: -- Calcium-channel blockers or thiazide-type diuretics are the most likely drugs to confer benefit as first-line treatment for most patients aged 55 or older. (Grade A* recommendation) -- People younger than 55 years, evidence suggests that initial therapy with an ACE inhibitor may be better than initial therapy with a calcium-channel blocker or a thiazide-type diuretic. (Grade C* recommendation) -- Beta-blockers In head-to-head trials, beta-blockers were usually less effective than a comparator drug at reducing major cardiovascular events, particularly stroke. Beta-blockers were also less effective than an ACE inhibitor or a calcium-channel blocker at reducing risk of diabetes, particularly in patients taking a beta-blocker and a thiazide-type diuretics. Thus, beta-blockers are no longer preferred as a routine initial therapy for hypertension. a. But consider them for younger people, particularly: -women of childbearing potential -patients with evidence of increased sympathetic drive -patients with intolerance of or contraindications to ACE inhibitors and angiotensin-ii receptor antagonists. (Grade B* recommendation) b. If a patient taking a beta-blocker needs a second drug, add a calcium-channel blocker rather than a thiazide-type diuretic, to reduce the patient s risk of developing diabetes. (Grade C* recommendation) c. If a patient s blood pressure is not controlled by a regimen that includes a betablocker (that is, it is still above 140/90mmHg), change their treatment by following the flow chart above. (Grade C* recommendation) d. If a patient s blood pressure is well controlled (that is, 140/90 mmhg or less) by a regimen that includes a beta-blocker, consider long-term management at their routine review. There is no absolute need to replace the beta-blocker in this case. (Grade C* recommendation) f. When withdrawing a beta-blocker, step down the dose gradually. Beta-blockers should not usually be withdrawn if a patient has a compelling indication for being treated with one, such as symptomatic angina or a previous myocardial infarction. (Grade C* recommendation) Page 7

9 -- Adding an ACE inhibitor to a calcium-channel blocker or a diuretic (or vice versa) is a logical combination, and had been commonly done in trials. (Grade B* recommendation) Clinical trial and guideline basis for compelling indications for individual drug classes Recommended Drugs Compelling Indication * Diuretic BB ACEI ARB CCB Aldomet Clinical Trial Basis Heart failure..... Postmyocardial infarction... High coronary disease risk.... Diabetes..... Chronic kidney disease.. Recurrent stroke prevention.. PROGRESS ACC/AHA Heart Failure Guideline, MERIT-HF COPERNICUS, CIBIS SOLVD, AIRE, TRACE, ValHEFT, RALES ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS ALLHAT, HOPE, ANBP2, LIFE, CONVINCE NKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK * Compelling indications antihypertensive drugs based on benefits from outcome studies or existing clinical guidelines, the compelling indication is managed in parallel with the BP. Conditions for which clinical trials demonstrate benefit of a specific classes of antihypertensive drugs. Page 8

10 5. Referral 5.1 Accident & Emergency Department Referral 9 i. Malignant Hypertension - Diastolic Pressure > 130 mmhg - Proteinuria - Papilloedema - Acute Pulmonary Oedema - Encephalopathy ii. Accelerated Hypertension Diastolic pressure > 130 mmhg + retinal haemorrhage. iii. Persistent BP > 220/120 mmhg despite appropriate resting or drug treatment (e.g. adalat retard 20 mg stat and review 1-2 hours afterwards) (sublingual Adalat treatment is not recommended). iv. Pregnancy (a) Hypertension (BP 140/90 mmhg) & > 20 weeks gestation; or (b) Signs and symptoms of pre-eclampsia (e.g. headache, proteinuria, oedema). 5.2 Hospital Clinic Referral 9 i. Suspected secondary hypertension. ii. Patients aged 30 or below. iii. Hypertension in pregnancy less than 20 weeks gestation without signs and symptoms of pre-eclampsia requires urgent obstetric referral. iv. Patients with progressive Target Organ Damage, not manageable at out-patient setting, (e.g. rapidly deteriorating renal function, intractable heart failure). v. Therapeutic problems (e.g. treatment resistance, multiple drug intolerance, multiple drug contraindication). Page 9

11 Appendix I Equipment for Recording Blood Pressure 1.1 Sphygmomanometer i. Mercury sphygmomanometer the most reliable type of instrument for recording blood pressure. ii. Electronic devices can also be used, but periodic calibration should be done to ensure its accuracy. iii. Electronic devices that record the pressure in the fingers or the wrist should be avoided. 1.2 Checking of mercury sphygmomanometer i. The column of the manometer is in the intended position (vertical). ii. Mercury level is at zero when cuff is deflated. iii. No blockage of the air venting system at the top of manometer. iv. A sluggish response or bouncing of the mercury column during inflation and deflation usually indicates a blocked vent. v. No leakage from rubber tubing, hand pump and control valve testing of control valve: a. roll a cloth cuff into its own tail. b. pump up to 200 mmhg and wait for 10 seconds. c. mercury should fall < 2 mmhg in 10 seconds. d. if fall > 2 mmhg, clamp circuit in sections to locate leak or replace the control valve. 1.3 Checking of electronic devices i. Routine checks - compare the reading with mercury sphygmomanometer. ii. Periodic calibration is needed. iii. If consistent discrepancies of more than 5 mmhg persist, refer to service manual or send the monitor to a trained technician or recognised unit (EMSD) for calibration. 2. Blood pressure recording techniques i. The client should be advised to be seated for at least 5 minutes before the recording is taken. ii. Arrange client in sitting position. iii. Remove any constrictive clothing from the arm. Page 10

12 iv. Support client s arm with the antecubital fossa at heart level. v. Use an appropriate sized blood pressure cuff. The cuff should be wide enough to cover two thirds of the upper arm and its length should be long enough to encircle the whole arm. vi. Advise client to relax and not to talk during blood pressure recording. vii. Check blood pressure initially by palpation prior to auscultation. a. palpate the radial artery with your fingertips. b. inflate the cuff while simultaneously palpating the artery. c. note the point on the manometer at which the radial artery pulsation is no longer palpable. (This is the estimated systolic pressure). d. deflate the cuff. viii. Wait seconds before reinflating. ix. Place the stethoscope gently over the brachial artery and steadily inflate the cuff to the level of 30 mmhg above the estimated level of systolic pressure checked by palpation. x. Deflate the blood pressure cuff by 2 mmhg per second. xi. Record the first Korotkoff sound ( the regular appearance of sound) as the systolic pressure. xii. Record the last Korotkoff sound (the disappearance of sound) as the diastolic pressure. If sounds persist to zero, or close to zero, use the muffling sounds (IV Korotkoff sound) to indicate diastolic pressure. xiii. Allow 30 seconds between blood pressure recordings. 3. Precautions about blood pressure recording 3.1 Recorder s precautions i. Read at eye level. ii. Avoid digital preference. The blood pressure reading should be corrected to the nearest 2 mmhg. iii. Choose the correct cuff size (see 2 v). iv. Consistent use of the 4th or 5th Korotkoff sounds for recording (see 2 xii). v. Correct arm positioning a. blood pressure changes 8-10 mmhg for every 10 cm the antecubital fossa is above or below the heart level. b. arm well supported (diastolic pressure may be raised by as much as 10%). vi. Deflate the cuff not too rapidly or too slowly (see 2 x). vii. Avoid venous congestion due to repeated measurement. Page 11

13 viii. Adopt a unify standard in recording routinely to avoid variation among recorders. 3.2 Client s factors i. Emotional extremes. ii. Physical exertion: blood pressure will increase during exertion. iii. After exercise, decrease in blood pressure may persist for more than one hour. iv. After meals: blood pressure may decrease following meals, recording is not recommended within half an hour of eating. v. Smoking and caffeine: should be avoided within 1-2 hours prior to BP recording. vi. Alcohol. vii. Temperature extremes. viii. Bladder and bowel distension. ix. Pain. Page 12

14 Appendix II Follow up 1. Seen at intervals not exceeding 6-monthly if BP is at goal & stable 3,4,5,6,7 2. Follow-up assessment (not exceeding 6-monthly) 3, 4, 6, 7, 8 Blood pressure Body weight 5, 9 Drug compliance 6, 9 5, 6,9 Side effect of drugs* Non-pharmacological: diet, smoking, obesity, exercise 3. At least annually 5, 10 Urine protein 4. When indicated 9, 10 Creatinine#* 9, 10 FBS, lipids# 9, 10 ECG# 5, 6, 9 *Include investigation: electrolytes if diuretics used, RFT if ACEI used. #WHO 6 /BHS 5 /EL 10 do not mention the significance of checking these parameters regularly. For those patients newly start ACEI, we suggest to check renal function 4-6 weeks after starting. Page 13

15 Height (cm): FLOW CHART ID no: Date BP BMI/ BW Urine protein Drug comp Drug side effect Poor diet Risk factors Smoker Insufficient Exercise Assessment & management (RFT, Lipid, FBS, ECG, etc) FU Page 14

16 Appendix III Ambulatory BP monitoring for white coat hypertension Introduction (1) White coat hypertension is common. The prevalence is about 20% among those with persistent elevation of clinic blood pressure. The incidence of target organ damage or cardiovascular morbidity and mortality is significantly less than comparing white coat hypertension with established hypertension. (2) 24-hour ambulatory blood pressure monitoring is the most frequent tool to measure the white coat effects. It is recommended by the British hypertension society guidelines and the Canadian hypertension society guidelines. Definition of white coat hypertension is an elevated daytime clinic blood pressure to 140/90 mmhg; while the daytime ambulatory blood pressure remains normal, i.e. <135/85 mmhg. 2. Aims To identify patients of suspected white coat hypertension by using validated ambulatory BP monitors. (TM-2420 model; validated by both US Association for the Advancement of Medical Instrumentation and British Hypertension Society.) 3. Procedures (1) Selection of subjects i. Clinic BP 140/90 on repeated measurements while home BP (BP outside clinic) < 140/90. ii. Not on anti-hypertensive treatment. iii. Must not be on NSAIDs, sympathomimetics, liquorice at time of monitoring. iv. For those who have acute intercurrent illnesses, acute stressful events and unstable psychiatric conditions, ABPM should be delayed. v. Hormones, steroids, anxiolytics and anti-depressants may all affect BP. If initiation of those drugs is deemed necessary, the subjects should be excluded. Stable patients on long-term treatment of those medicines should NOT be excluded. vi. Subjects with target organ damage should be excluded. Page 15

17 (2) Prior arrangement should be made with doctor(s) responsible for ambulatory BP monitoring. (3) 4 monitors were located in Ngau Tau Kok Family Medicine Centre and the three Families Clinics. The explanation, set up and removal of monitor will be performed there. (4) Interpretation of the results will be done by the Ambulatory BP team. (5) Results will be mailed back to referred clinic within 2 weeks. Page 16

18 Appendix IV Home/self BP monitoring 27 There is an increasing use of home or self BP measurement. Some of the monitors used are inaccurate and many have not been formally validated. We strongly recommend the proper use of accurate, validated and well-maintained monitors, with an appropriate cuff size. Wrist monitors, in most instances, are not as accurate as upper arm devices and are not recommended. Measurements should be made under standardised conditions. The potential advantages of home monitoring include: the availability of multiple recordings throughout the waking period taken over many days, which may reduce white coat effect and misinterpretation of measurement variability. Importantly, home BP measurement also involves the patient more closely in the management of their own BP. Values from home measurements tend to be lower than clinic levels. Consequently, thresholds and targets of treatment based on this technique should probably be adjusted downwards (eg by 10/5mmHg), although evidence for true equivalence is lacking and will be variable. The disadvantages of this technique include reporting bias, and unsupervised alteration of medication. Newer BP monitors offer the advantages of built-in printers or internally storing all BP measurements, which can be subsequently downloaded via a telephone link to the physician. There is no uniform consensus about the frequency and timing of measurements, or about what levels should be regarded as abnormal, but patients with home BP levels of SBP <130mmHg and DBP <85mmHg can probably be regarded as having BP levels within the normal range. It has been suggested that initial assessment or the assessment of treatment effects should be for a 7-day period, with recordings performed in the morning and evening, and excluding values for the first 24 h. The average of at least these 12 readings is then taken as the home BP level. The potential advantages of home BP monitoring notwithstanding, there is to date, little or no evidence of these recordings predicting CVD risk or outcomes more effectively than clinic readings. Page 17

19 Appendix V Levels of evidence 4 Page 18

20 Appendix VI Classification of obesity (WHO IOTF 2000) 26 Classification BMI (kg/m²) Risk of co-morbidities Underweight < 18.5 Normal range Average Overweight: Pre-obese Obese I Obese II Low (but increased risk of other clinical problems) Increased Moderate Severe After consideration of the WHO classification and the Asia-Pacific perspective, it s our group consensus to adopt the above in the protocol. Page 19

21 Appendix VII Clinic available anti-hypertensive drug list and cost Class Drug (Trade name) Cost HKD Thiazide diuretics Indapamide (Natrilix) Loop diuretics Frusemide (Lasix) 20mg 0.05 Potassium sparing diuretics Moduretic Dyazide Aldosterone receptor blockers Spironolactone (Aldactone) Beta-blockers ACE inhibitors Calcium channel blockers Alpha1-blockers Atenolot (Tenormin) Metrprolol (Betaloc) Propanolol (Inderal) Captopril (Capoten) Enalapril (Renitec) Lisinopril (Zestril) Perindopril (Acertil) Nifedipine (Adalat) Nifedipine SR (Adalat Retard) Amlodipine (Norvasc) Felodipine (Plendil) Prazosin (Minipress) Terazosin (Hytrin) 50mg mg mg mg mg mg mg mg mg mg 0.8 5mg mg mg mg mg mg mg mg mg mg mg mg mg mg 1.3 2mg 1.6 Centrally acting drugs Methyldopa (Aldomet) 125mg mg Page 20

22 References 1. Whelton P K. Epidemiology of hypertension. Lancet 1994;344: Janus E.D. Hong Kong Cardiovascular Risk Factor Prevalence Study The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, US Department of Health and Human Services. National Institutes of Health, National Heart, Lung and Blood Institute. 4. Hypertension: management of hypertension in adults in primary care, June National Institute for Health and Clinical Excellence (NICE). 5. Byran Williams et al. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV). BMJ 2004;328; World Health Organizaton (WHO)/International Society of Hypertension (ISH) statement on Management of Hypertension. J Hypertension 2003; 21(11); Department of General Practice & Primary Health Care, University of Leicester (Eli Lilly). Management of Hypertension In Primary Care. 8. Vasan RS, Larson MG, Leip EP, et al. Assessment of frequency of progression to hypertension in nonhypertensive participants in the Framingham Heart Study: A cohort study. Lancet 2001;358: HT Working Group ( ). Department of Health Hypertension Protocol for GOPD. 10. Working Group on Clinical Practice Guidelines for Integrated Health Service for the Elderly (Dec, 2000). Clinical Practice Guidelines for Elderly Health Centres 3 rd Edition. 11. U.S. Preventive services Task Force. Counseling to Prevent Tobacco Use (March 1994). Screening for Hypertension. Screening for Obesity. 12. Stuant et al. Primary prevention of cardiovascular disease. Clinical Evidence Issue p BMJ Publishing Group. 13. Michael Pignone, Cynthia D Mulrow. What are the elements of good treatment for hypertension? Evidence based management of hypertension. BMJ 5 May 2001;322: Chan S. The management of hypertension in the acute setting. HK Pract. 2001;23: O Brien E. et al. Use and interpretation of ambulatory blood pressure monitoring: recommendations of the British Hypertension Society. BMJ 22 April 2000; 320: The National High Blood Pressure Education Program Coordinating Committee. National High Blood Pressure Education Program Working Group Report on Ambulatory Blood Pressure Monitoring. Archives of Internal Medicine 1990; 150: Grin J.M. et al. Management of Hypertension after Ambulatory Blood Pressure Monitoring. Annals of Internal Medicine 1993; 118: Appel L.J. et al. Ambulatory Blood Pressure Monitoring and Blood Pressure Self- Measurement in the Diagnosis and Management of Hypertension. Annals of Internal Medicine 1993; 118: American College of Physicians. Automated Ambulatory Blood Pressure Devices and Page 21

23 Self-Measured Blood Pressure Monitoring Devices: Their Role in the Diagnosis and Management of Hypertension. Annals of Internal Medicine 1993; 118: O Connor D.B. et al. Are occupational stress levels predictive of ambulatory blood pressure in British GPs? An exploratory study. Family Practice 2001; 18: McAlister F.A. et al. Measurement of blood pressure: an evidence based review. BMJ 2001; 322: O Brien E. et al. ABC of hypertension: Blood pressure measurement. BMJ 5 May 2001; vol.322: Hypertension Guideline (Second Edition), Professional Development and Quality Assurance, Clinical Audit and Guideline Group, Department of Health Hypertension Protocol (Second Edition). 24. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker against diuretic: The Antihypertensive and Lipid-lowering Treatment to Prevent Heart Attack Trial (ALLHAT) JAMA 2002;288: Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Brag GA, Harsha D, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001;344: The Asia-Pacific perspective: Refinding obesity and its treatment (2000). 27. Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JP, Sever PS and Thom S McG; The BHS Guidelines Working Party Guidelines for Management of Hypertension: Report of the Fourth Working Party of the British Hypertension Society, BHS IV. Journal of Human Hypertension 2004; 18: Page 22

24 Members of the Clinical Audit and Guideline Group, PDQA, Department of Health Group Leader : Dr. HUI Yin-fun, Linda Coordinators of the HT guideline, third edition : Dr. NG Mei-yee Members : 1. Dr. CHENG Pui-kwan, Lisa 2. Dr. KONG Che-wan, Leo 3. Dr. LAM Wing-kwun Special thanks to KWOK Chi-kong for cover design. Correspondence to : Dr. NG Mei-yee Address : Chai Wan Families Clinic, Department of Health 1 st Floor, Main Block, PYNEH, Chai Wan, HK.. Fax : Dr. Ng Mei Yee: johnhli@netvigator.com Footnotes Funding : None Competing interests : None Last modified : November 2008 This protocol is scheduled for review at 1 year or earlier as appropriate. Comments and suggestions are welcomed and should be addressed to the group coordinators. Page 23

25 Disclaimer Every effort has been made to ensure the accuracy and completeness of this version of protocol. However, we make no warranties regarding errors or omissions and assume no responsibility or liability for loss or damage resulting from the use of information contained within. We cannot endorse, or appear to endorse, derivative or excerpted materials, and it cannot be held liable for the content or use of adapted products. Any adaptations of this protocol must include a disclaimer to this effect. Advertising or implied endorsement for any commercial products or services is not permitted. Guideline Availability Additional copies can be obtained by contacting PDQA, Department of Health. ~ E N D ~ Page 24